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Credentialing and Provider Enrollment: Improved Solutions Are Desired for 2018

April 1, 2021
April 1, 2021

Medical groups, hospitals, and healthcare organizations are facing an uncertain healthcare environment, escalating costs, and declining reimbursements. These organizations continue to seek strategies and solutions to decrease costs, increase revenue, and accelerate their provider enrollment process in order to obtain more timely reimbursement.

It is against this backdrop that VerityStream examined the current and changing landscape of provider enrollment and the implications for medical groups, hospitals and healthcare organizations. We present our research collected in early 2017 from 505 credentialing and provider enrollment professionals throughout the U.S. who indicate that creating efficiency and automation are higher priorities in their organization than in recent years. Here are some general conclusions we draw from the survey results:

Current Methods Are Not Satisfactory

Organizations are seeking alternative methods within their region and state to form healthcare collaborative relationships with payers as a method to secure revenue-saving opportunities for the collaborative healthcare organization members. These arrangements typically include delegated credentialing agreements.

Healthcare organizations look to develop payer enrollment processes which generate dashboard outcome data to report the time it takes to onboard providers with commercial payers, Medicaid, and Medicare. The outcome metrics are methods to monitor efficiencies, which include revenue dollars on hold attributed to payer enrollment. Imagine the value of shaving off 7 to 15 days from the time it takes to enroll a provider.

Paper and Spreadsheets Are Not Working with Adequate Speed

Leaders are looking to optimize software solutions which provide methods to improve efficient communication and required payer ongoing verifications, as well as integration with the Council for Accountable Quality Healthcare (CAQH), State Medicaid, and Medicare enrollment.

  • Many healthcare organizations continue to manage provider enrollment by keeping data in paper files, excel spreadsheets, access, and homegrown databases. Having a single-source database solution cannot be understated as an opportunity to manage verified provider data—remember that organizations need one place that manages communication between departments related to provider locations, phone numbers, etc. in order to assure that accurate data is provided to the public.
  • Valuable staff time is spent completing paper applications for Medicare provider enrollment, as opposed to the Internet-based Provider Enrollment Chain and Ownership System (PECOS). The Centers for Medicare and Medicaid Services (CMS) reports initial payer enrollment is completed on the average within 45 days when submitted electronically, as opposed to 60 days when submitted in paper. 2
  • The benefit of creating parallel workflow processes, which are kicked off simultaneously, minimizes redundancies, improves the provider experience, and payer enrollment onboarding timeframes.
  • Crucial documentation of payer enrollment verification of effective date(s) can be maintained in a software enrollment solution. The image documentation is a valuable resource when contesting payer effective dates related to denied claims, as well as when audited by CMS.
  • CMS and commercial payers have heightened their scrutiny of provider directories to ensure patient access to care. Provider enrollment has had to implement processes to ensure complete and correct provider data, which feeds downstream databases within their organizational, internal, and public-facing provider directories. CMS issued an Executive Summary dated January 17, 2017 providing results of Medicare Advantage online directory audits completed in 2016. The report states 45.1% of provider locations were inaccurate. CMS issued 52 compliance actions to the 54 parent organizations that were audited.

Attention to the Bottom Line

There is no denying the heightened awareness of provider enrollment’s impact on a healthcare organization’s financial bottom line. Over 50% of those who participated in the survey have been working in their current role for over fifteen years. These individuals are—in many organizations—taking the lead to improve processes. The survey results from the over 500 credentialing and provider enrollment professionals provides crucial data to confirm the need for substantial change. The challenge for today’s credentialing and provider enrollment professionals is to identify best practices in payer enrollment and incorporate those best practices, industry requirements, and Medicare and Medicaid regulations using available technology and marshalling stakeholders within the organization that have vital data to contribute to an accurate data set. The call to action is compelling—the financial health of our healthcare organizations depends upon a well-orchestrated and coordinated approach and leadership from the executive suite.

About VerityStream

VerityStream delivers enterprise-class solutions that are transforming credentialing, enrollment, privileging, and evaluation for healthcare organizations across the United States. We currently serve over 2,500 hospitals and 1,300 outpatient care settings in the U.S. including ambulatory surgery centers, urgent cares, and medical groups. VerityStream and our solutions resulted from the merging of Sy.Med, HealthLine Systems, Morrisey, and CredentialMyDoc representing over 75 years of industry experience. HealthStream, (NASDAQ: HSTM), based in Nashville, TN, is our parent company, supporting us through innovation, investment, and the development of market-leading products. VerityStream has over 225 employees spanning headquarters in Boulder, CO and satellite offices in San Diego, CA; Nashville, TN; Chicago, IL; and Savannah, GA.